Multidisciplinary Approach to New Pathway Cuts CAUTI Rates

Every year in the U.S., 13,000 people die from catheter-associated urinary tract infections (CAUTI), as bacteria can spread from the bladder to the kidneys and bloodstream potentially leading to septic shock and death.

University of Chicago Medicine’s nursing staff, in partnership with physicians, infection control, CBIS and other departments, is using a new evidence-based protocol that has significantly lowered CAUTI rates, improved the experience of patients and potentially saved lives in the process.

“What really helped is that every single discipline that we’ve been trying to work with has been very engaged this past year,” said Rachel Marrs, MSN, RN, the lead infection control practitioner in the University of Chicago Medical Center’s Infection Control Program.

The Standard Pathway for the Prevention of Catheter-Associated Urinary Tract Infections was introduced at the beginning of March after months of work analyzing existing procedures and reviewing literature by representatives of the Center for Nursing Professional Practice and Research and other areas of UCM.

The Pathway is a workflow-type process managed by nurses that essentially asks the question: “Does this patient still need an indwelling urinary catheter?”

If patients meet at least one of the criteria outlined in the Pathway, which follows the Centers for Disease Control and Prevention guidelines, then the catheter remains in place. For instance: the catheter will remain if urinary output measurements are needed for critically ill patients, the patient has had surgery in an adjacent area, or incontinence will aggravate an existing skin problem.

But as Marrs noted: “The biggest risk factor for getting a CAUTI is having a catheter.”

So when patients don’t meet the criteria, nurses can remove the devices, and in turn reduce the risk of infection.

“When the patient no longer meets the criteria, under this Pathway the nurse is able to remove the catheter without a physician’s order,” said Judy Doty, MSN, RN, Manager, Nursing Quality.

In fiscal 2014, there were 58 patients with CAUTI – a 26 percent drop from the 78 patients who had the infections in fiscal 2013.

“We had 20 less patients that got an infection this past year,” Marrs said proudly. “Not only does that potentially increase a patient’s overall satisfaction, but it also could help decrease costs, length of stay and help avoid unnecessary treatment.”

The overall CAUTI rate for FY2014 was 2.03 out of 1,000 urinary catheter days better than expected. The target for the current fiscal year is to reduce that figure to 1.71 out of 1,000 urinary catheter days. The Standardized Infection Ratio (SIR), which tracks hospital-acquired infections over time and compares an institution’s performance with a baseline rate in the general U.S. population, was 0.91 in FY14. The goal for FY15 is 0.81.

Jessica Ridgway, MD, Assistant Professor of Medicine and Associate Hospital Epidemiologist, was one of the physicians who coordinated the development of the new protocol.

Along with Michael Howell, MD, MPH, Associate Professor of Medicine and Associate Chief Medical Officer for Clinical Quality, she helped navigate the protocol through the approvals process by various physicians’ groups and the medical executive committee.

Ridgway said the improving metric is also based on work that’s been done with the hospital’s lab, as health care providers work to figure out if signs of an infection in a urine sample reflect colonization of the catheter itself or an actual infection in the patient.

“It’s a great interdisciplinary effort,” said Ridgway.

Meanwhile, there have been major strides in improving how urine samples are collected. That helps determine whether the patient arrived with an infection, developed the infection in the hospital, or is showing markers of something else that is not an infection requiring treatment.

Education and technology have also played key roles in the improvement in the quality and safety metric. Practices around how catheters are inserted, cared for and maintained have been standardized and nurse educators have ensured the staff has the required skills. And leaders worked with EPIC to construct a signaling mechanism when nurses signed onto the system, triggering a best-practice alert for each shift to review whether a catheter was still required.

Those involved in the CAUTI effort also praised UCMedicine’s supply chain staff, who worked with the nursing staff and other leaders to try various incontinence products that can wick moisture away from the skin. This helps provide some measure of confidence for nurses who can order removal of a catheter to lower the risk of CAUTI without compromising the chance for moisture-associated skin damage in their patients.

“We have been working on CAUTI prevention for several years,” said Marrs. “But we’re glad we have the Standard Pathway in place and it’s working well.”